Healthcare Provider Details

I. General information

NPI: 1225611296
Provider Name (Legal Business Name): SANDY SULLIVAN NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 HUNTSVILLE HWY
FAYETTEVILLE TN
37334-3787
US

IV. Provider business mailing address

1816 HUNTSVILLE HWY
FAYETTEVILLE TN
37334-3787
US

V. Phone/Fax

Practice location:
  • Phone: 931-227-4227
  • Fax:
Mailing address:
  • Phone: 931-227-4227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number41012
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number41012
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: